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1.

Purpose

Standardized care via a unified surgeon preference card for pediatric appendectomy can result in significant cost reduction. The purpose of this study was to evaluate the impact of cost and outcome feedback to surgeons on value of care in an environment reluctant to adopt a standardized surgeon preference card.

Methods

Prospective observational study comparing operating room (OR) supply costs and patient outcomes for appendectomy in children with 6-month observation periods both before and after intervention. The intervention was real-time feedback of OR supply cost data to individual surgeons via automated dashboards and monthly reports.

Results

Two hundred sixteen children underwent laparoscopic appendectomy for non-perforated appendicitis (110 pre-intervention and 106 post-intervention). Median supply cost significantly decreased after intervention: $884 (IQR $705–$1025) to $388 (IQR $182–$776), p < 0.001. No significant change was detected in median OR duration (47 min [IQR 36–63] to 50 min [IQR 38–64], p = 0.520) or adverse events (1 [0.9%] to 6 [4.7%], p = 0.062). OR supply costs for individual surgeons significantly decreased during the intervention period for 6 of 8 surgeons (87.5%).

Conclusion

Approaching value measurement with a surgeon-specific (rather than group-wide) approach can reduce OR supply costs while maintaining excellent clinical outcomes.

Level of Evidence

Level II.  相似文献   

2.

Purpose

We sought to examine donor mesenchymal stem cell (MSC) kinetics after transamniotic stem cell therapy (TRASCET) in experimental spina bifida.

Methods

Pregnant Sprague–Dawley dams exposed to retinoic acid for the induction of fetal neural tube defects received volume-matched intra-amniotic injections on gestational day 17 (E17; term = E22): either amniotic fluid MSCs (afMSCs) labeled with a luciferase reporter gene (n = 78), or luciferase protein alone (n = 66). Samples from twelve organ systems from each surviving fetus with spina bifida (total n = 60) were screened via microplate luminometry at term.

Results

Donor afMSCs were identified exclusively in the placenta, umbilical cord, spleen, bone marrow, hip bones, defect, and brain. Luminometry was negative in control fetuses receiving luciferase alone (p < 0.001). Signal intensity in relative light units (RLUs) was moderately correlated between the defect and the hip bones (rho = 0.38, p = 0.048), and between the placenta and the brain (rho = 0.40, p = 0.038).

Conclusions

Amniotic mesenchymal stem cells engraft to specific sites after concentrated intra-amniotic injection in the setting of spina bifida. A hematogenous route encompassing the bone marrow as well as distant central nervous system homing are fundamental constituents of cell trafficking. These findings must be considered during eventual patient selection for transamniotic stem cell therapy in the prenatal management of spina bifida.  相似文献   

3.

Background/Purpose

Although advances have been made in the prenatal diagnosis of esophageal atresia (EA), most neonates are not identified until after birth. The distended hypopharynx (DHP) has been suggested as a novel prenatal sign for EA. We assess its diagnostic accuracy and predictive value on ultrasound (US) and magnetic resonance imaging (MRI), both alone and in combination with the esophageal pouch (EP) and secondary signs of EA (polyhydramnios and a small or absent fetal stomach).

Methods

We retrospectively reviewed fetal US and MRI reports and medical records of 88 pregnant women evaluated for possible EA from 2000 to 2016. Seventy-five had postnatal follow-up that confirmed or disproved the diagnosis of EA and were included in our analysis.

Results

Seventy-five women had 107 study visits (range 1–4). DHP and/or EP were seen on US and/or MRI in 36% of patients, and 78% of those patients had EA. DHP was 24% more sensitive for EA than EP, while EP was 30% more specific. After 28 weeks of gestation, DHP had a predictive accuracy for EA of 0.929 (P = 0.001).

Conclusions

DHP is a sensitive additional prenatal sign of EA. More accurate diagnosis of EA allows for improved counseling regarding delivery, postnatal evaluation, and surgical correction.

Type of Study

Diagnostic.

Level of Evidence

Level II.  相似文献   

4.

Introduction

The purpose of this study was to evaluate clinical outcomes in children with asymptomatic congenital lung malformations (CLM) who were initially managed nonoperatively.

Methods

An IRB-approved retrospective review was performed on all CLMs at a single tertiary care referral center (Jan 2006–Dec 2016, n = 140). Asymptomatic cases that did not undergo elective resection were evaluated for subsequent CLM-related complications based on clinical records and a telephone quality of life survey.

Results

Out of 39 (27.9%) who were initially managed nonoperatively, 13 (33%) developed CLM-related symptoms and underwent surgical intervention at a median age of 6.8 years (range, 0.7–19.8 years). The most common indication for conversion to operative management was pneumonia (78%). Larger lesions, as measured by CT scan, were significantly associated with the need for subsequent surgical intervention (mean maximal diameter, 5.7 vs. 2.9 cm; p = 0.005). Based on survey data with a median follow up of 3.9 years (range, 0.2–13.2 years), 17% developed chronic pulmonary symptoms, including cough (11%) and asthma requiring bronchodilators (12%).

Conclusion

Although these data support nonoperative management as a viable alternative to surgical resection, at least one-third of CLM children eventually develop pneumonia or other pulmonary symptoms. Larger lesions are correlated with an increased risk for eventual surgical resection.

Level of Evidence

Level IV.  相似文献   

5.
  相似文献   

6.
Prenatal observed/expected lung–to-head ratio (O/E LHR) by ultrasound correlates with postnatal mortality for congenital diaphragmatic hernia (CDH) patients. The aim of this study is to determine if O/E LHR correlates with pulmonary hypertension (PH) outcomes for CDH patients.

Methods

A single center retrospective chart review was performed for CDH neonates from January 1, 2006, to December 31, 2015, (REB #1000053124) to include prenatal O/E LHR, liver position, first arterial blood gas, repair type, echocardiogram (ECHO), and lung perfusion scan (LPS) results up to 5 years of age.

Results

Of 153 newborns, 123 survived (80.4%), 58 (37.9%) had prenatal O/E LHR, and 42 (27.5%) had postnatal ECHO results. High mortality risk neonates (O/E LHR ≤ 45%) correlated with higher right ventricular systolic pressure (RVsp) at birth. Generally PH resolved by age 5 years. LPS results did not change over time (p > 0.05) regardless of initial PH severity, suggesting that PH resolution did not correlate with increased ipsilateral lung perfusion to offload the right ventricle.

Conclusion

Prenatal prognostic markers correlated with initial PH severity for CDH newborns, but PH resolved over time despite fixed perfusion bias to the lungs. These results suggest favorable PH outcomes for CDH patients who survive beyond infancy.

Type of Study

Retrospective Cohort Study.

Level of Evidence

3b  相似文献   

7.

Purpose

Donor cell engraftment patterns following transamniotic stem cell therapy (TRASCET) with amniotic fluid mesenchymal stem cells (afMSCs) are incompatible with solely direct amniotic seeding. We sought to determine whether fetal bone marrow is a component of such engraftment and to examine the chronology of afMSC placental trafficking.

Methods

Two groups of Sprague–Dawley rat fetuses received volume-matched intraamniotic injections on gestational day 17 (E17; term E22): either afMSCs labeled with a luciferase reporter gene or luciferase protein alone. Placental samples were procured at daily time points thereafter until term. Fetal bone marrow was obtained at term only owing to size constraints. Specimens were screened for luminescence via microplate luminometry.

Results

Donor afMSCs were identified in the bone marrow and placenta of fetuses receiving labeled afMSCs, but not in those receiving luciferase alone (P < 0.001). Luminescence was significantly higher in placentas at E18 compared to E19 (P < 0.001), E20 (P = 0.007), and E21 (P = 0.004), with no difference with E22/term (P = 0.97).

Conclusions

Donor mesenchymal stem cells home to the fetal bone marrow after intraamniotic injection. The chronology of placental trafficking is suggestive of controlled cell routing rather than plain cell clearance. Fetal bone marrow engraftment of donor cells significantly expands potential applications of transamniotic stem cell therapy.  相似文献   

8.

Background & objectives

Congenital Diaphragmatic Hernia (CDH) is associated with significant morbidity and mortality. This study compares the efficacy of the highest oxygenation index in the first 48 h (HiOI) versus current prenatal indices to predict survival and morbidity.

Methods

Medical records of 50 prenatally diagnosed, isolated, left-sided CDH patients treated from January 2011 to April 2016 were reviewed. Data abstracted included HiOI, lung to head ratio (LHR), observed to expected total fetal lung volume (O/E TFLV), percent liver herniation (%LH), 6 month survival, respiratory support at discharge, ventilator days and length of stay. Data were analyzed using parametric and nonparametric tests and regression analyses as appropriate.

Results

HiOI was associated with significantly increased LOS (p < 0.001), respiratory support at discharge (p < 0.001), greater ventilator days (p = 0.001) and higher odds of death (p = 0.004) with risk of death increasing by 5% for every one-unit increase in OI. HiOI was statistically a better predictor of LOS than O/E TFLV (p = 0.007) and %LH (p = 0.02).

Conclusions

In isolated, left-sided CDH patients, HiOI is associated with higher mortality, greater length of stay, more ventilator days and increased respiratory support at discharge. HiOI is a better predictor of length of stay than O/E TFLV and %LH.

Type of study

Retrospective Study

Level of evidence

II  相似文献   

9.

Background

Port-a-cath (PAC) is an essential device in the management of the patients of chronic illness, but despite theirs benefits there are many complications either at the time of insertion or at time of removal. Our aim of this study is to evaluate the fracture rate of the catheter at removal time in comparison with catheter type either polyurethane or silicone.

Methods

A retrospective monocentric study of all PACs which were removed at our university pediatric hospital between 1 January 2006 and 31 December 2016. Two groups were compared: polyurethane group and silicone group.

Results

Total of 216 central lines were removed, the mean age at the time of extraction was 9.7 ± 4.9 years and the mean time for both catheter was 2.7 ± 1.6 years, fracture occurred in 11 catheter of the polyurethane group (n = 119), with no fracture of silicone group (n = 86), in the polyurethane group, the risk of catheter fracture is significantly related to the duration of the PAC in place.

Conclusion

We found that the polyurethane-based catheters are more vulnerable for rupture and retained fragment in the blood vessels, especially if left in place for long time, for this reason we have switched to silicone-based catheter and all catheters should be remove within duration maximal of 2 years.

Type of study

Prognosis study.

Level of evidence

Level II.  相似文献   

10.

Introduction

Renal artery occlusive disease is poorly characterized in children; treatments include medications, endovascular techniques, and surgery. We aimed to describe the course of renovascular hypertension (RVH), its treatments and outcomes.

Methods

We performed literature review and retrospective review (1993–2014) of children with renovascular hypertension at our institution. Response to treatment was defined by National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents at most-recent follow-up.

Results

We identified 39 patients with RVH. 54% (n = 21) were male, with mean age of 6.93 ± 5.27 years. Most underwent endovascular treatment (n = 17), with medication alone (n = 12) and surgery (n = 10) less commonly utilized. Endovascular treatment resulted in 18% cure, 65% improvement and 18% failure; surgery resulted in 30% cure, 50% improvement and 20% failure. Medication alone resulted in 0% cure, 75% improvement and 25% failure. 24% with endovascular treatment required secondary endovascular intervention; 18% required secondary surgery. 20% of patients who underwent initial surgery required reoperation for re-stenosis. Mean follow-up was 52.2 ± 58.4 months.

Conclusions

RVH treatment in children includes medications, surgical or endovascular approaches, with all resulting in combined 79% improvement in or cure rates. A multidisciplinary approach and individualized patient management are critical to optimize outcomes.

Type of Study

Retrospective comparative study

Level of evidence

Level III  相似文献   

11.

Background

Lung clearance index (LCI) detects early ventilation inhomogeneity and has been suggested as sensitive endpoint in multicenter intervention trials in infants and preschoolers with cystic fibrosis (CF). However, the feasibility of multicenter LCI in this age group has not been determined. We, therefore, investigated the feasibility of LCI in infants and preschoolers with and without CF in a three-center setting.

Methods

Following central training, standardized SF6-MBW measurements were performed in 73 sedated children (10 controls, 49 with CF and 14 with other lung diseases), mean age 2.3 ± 1.2 years across three centers, and data were analyzed centrally.

Results

Overall success rate of LCI measurements was 91.8% ranging from 78.9% to 100% across study sites. LCI was increased in patients with CF (P < 0.05) and with other lung diseases (P < 0.05) compared to controls.

Conclusion

Our results support feasibility of LCI as multicenter endpoint in clinical trials in infants and preschoolers with CF.  相似文献   

12.

Background/purpose

The purpose of this study was to explore clinical characteristics and primary surgical diagnoses associated with in-hospital death in pediatric surgical patients admitted to the neonatal intensive care unit (NICU) of a tertiary hospital.

Methods

This retrospective study includes all patients admitted to our NICU for pediatric surgical diseases between January 2001 and December 2015. Univariate and multivariate binary logistic regression were performed to assess independent factors associated with in-hospital death.

Results

A total of 440 cases were included and 334 (83.5%) patients underwent one or more surgeries. Thirty six patients (8.2%) died while hospitalized in the NICU. The 5 most common surgical diagnoses were intestinal atresia/stenosis, anorectal malformation, congenital diaphragmatic hernia (CDH), esophageal atresia, and urinary system disorder. Necrotizing enterocolitis (NEC) had the highest mortality rate. Using logistic regression, in-hospital death was predicted by extremely low birth weight (ELBW) (odds ratio (OR) = 6.594; P = 0.006), CDH (OR = 13.954; P < 0.001), and NEC (OR = 8.991; P = 0.049).

Conclusions

This study describes CDH, NEC, and ELBW are independent predictive factors associated with in-hospital death of pediatric surgical patients in our NICU. Novel approaches for those conditions are required to improve the survival.

Type of study

Prognostic

Levels of evidence

II.  相似文献   

13.
  相似文献   

14.

Aim

Renal tubular dysfunction (RTD) causing obligate production of hypoosmolar urine in boys with posterior urethral valves (PUVs) has been described. It is not known how clinically significant this is. We hypothesize that a feedback loop is present in many PUV boys who suffer deterioration of their lower urinary tract (LUT). RTD results in hypoosmolar urine, obligate polyuria, and bladder stretch-injury. The increasing back-pressure worsens RTD, thus exacerbating the injury. Coexisting renal dysplasia and acquired renal scarring exacerbate this.We compared the concentrating ability (random clinic urine osmolality) of PUV boys who had no LUT deterioration to those who required intervention, examining the confounding effect of renal impairment with a subgroup analysis comparing those with plasma creatinine ≤ 80 μmol/l.

Methods

A retrospective review of our PUV database was performed. Age, intervention, and highest recorded random clinic urine osmolality (> 1 year) with concurrent plasma creatinine were recorded (normal urine osmolality 500–850 mOsm/kg). Data are given as median values, analyzed by Mann–Whitney u-test, with P < 0.05 deemed significant.

Main results

Urine osmolality was available in 77 boys with PUV out of 125 in our series. Of these, 34 required subsequent intervention (e.g., Mitrofanoff procedure, bladder augmentation). Age at testing trended towards being higher in the intervention group [7.9 (4.3–10.9) years vs. nonintervention 6.3 (4–8.4); P = 0.06]. Urine osmolality was significantly reduced in the intervention group [411(293–547) vs. 631 (441–805) mOsm/kg; P < 0.001]. Subgroup analysis comparing only those with creatinine ≤ 80 μmol/l was respectively 451 (322–567) mOsm/kg (n = 22) vs. 645 (469–810) mOsm/kg (n = 40), P < 0.01.

Conclusion

This study confirms that hypoosmolar urine is highly associated with progression of LUT dysfunction, requiring intervention. Even boys with normal creatinine values have a greater risk of LUT deterioration if they have a RTD and produce hypoosmolar urine.

Level of evidence

IV (retrospective service development project).  相似文献   

15.

Background

Pediatric Crohn's disease (CD) is increasing in incidence globally. Trends in specific types of inpatient pediatric CD-related surgical procedures have not been widely reported.

Methods

Patients ≤ 20 years of age with CD were identified in the Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Bowel resection, stoma creation, and perianal or percutaneous drainage procedures were identified using ICD-9 procedure codes, and trends were identified. Logistic regression was used to identify factors associated with surgical intervention and trends.

Results

Rates of overall bowel resection (including ileocolic resection, other small bowel resection, or other colon resection) did not change significantly over time. However, the odds of having a laparoscopic colon resection increased by 41% annually (p < 0.001). Rates of subsequent ileostomy formation increased (odds ratio 1.09, p < 0.001). Older age, male sex, fewer comorbidities, and treatment in large urban teaching hospitals were also associated with higher odds of undergoing bowel resection.

Conclusions

This study noted a stable rate of all types of bowel resections and increase in post resection ileostomy formation in US pediatric inpatients with CD from 2003–2012. Other rates of many CD-related procedures have remained stable. Further studies correlating the effects of biologic agents on surgical rates are warranted.

Type of study

Treatment Study

Level of evidence

Level III.  相似文献   

16.

Background

Esophageal atresia with or without tracheoesophageal fistula (EA/TEF) is a complex disorder, and most outcome data are confined to mortality and feeding-related morbidities. Our objective was to examine mortality, growth and neurodevelopmental outcomes in a large recent cohort of infants with EA/TEF.

Methods

Single center study of EA/TEF infants referred from January 2000 to December 2015. Data collected included associated defects, neonatal morbidity and mortality and growth and neurodevelopmental outcomes at age 12–36 months. Multiple regression analysis was used to determine variables associated with adverse outcome.

Results

Of the 253 infants identified, 102 infants (40%) were preterm. Overall mortality was 8.3%, the majority from major cardiac malformations (p < 0.001) Neurodevelopmental assessments (n = 182) showed that 76% were within normal, while some delay was seen in 24%, most often in expressive and receptive language. Nine infants had hearing impairment and 5 had visual impairment. Gastrostomy tubes were required in 47 patients and 15% continued to have weight growth velocities less than the 10th centile. A number of specialist interventions were required, Speech/Language being frequent.

Conclusion

Mortality in EA/TEF is primarily related to concomitant anomalies, especially cardiac. Multidisciplinary follow up is important for early identification and intervention for growth failure and developmental delay.

Type of study

Retrospective study

Level of evidence

Level II  相似文献   

17.

Background/Purpose

Our previously published data suggested several risk factors for infection after the Nuss procedure. We aimed to further elucidate these findings.

Methods

An IRB-approved (14–03-WC-0034), single institution, retrospective review was performed to evaluate the incidence of postoperative Nuss bar infections associated with seven variables. These were subjected to bivariate and multivariable analyses. A broad definition of infection was used including cellulitis, superficial infection with drainage, or deep infection occurring at any time postoperatively.

Results

Over 7 years (4/1/2009–7/31/2016), 25 (3.2%) of 781 patients developed a postoperative infection after primary Nuss repair. Multivariable analyses demonstrated an increased risk of infection with perioperative clindamycin versus cefazolin for all infections (AOR 3.72, p = .017), and specifically deep infections (AOR 5.72, p = .004). The risk of a superficial infection was increased when antibiotic infusion completed > 60 min prior to incision (AOR 10.4, p = .044) and with the use of peri-incisional subcutaneous catheters (OR 8.98, p = .008).

Conclusion

Following primary Nuss repair, the rate of deep bar infection increased with the use of perioperative clindamycin rather than cefazolin. The rate of superficial infection increased when perioperative antibiotic infusion was completed more than 60 min prior to incision and with the use of peri-incisional subcutaneous catheters. Further studies are needed to better understand these findings.

Type of study

Retrospective chart review.

Level of evidence

Level III treatment study.  相似文献   

18.

Purpose

There is debate regarding the optimal timing of central line removal in the neonatal intensive care unit (NICU). The purpose was to evaluate outcomes of idle peripherally inserted central catheters (PICCs) and tunneled central venous catheters (TCVCs) and determine the incidence of line-related infections and replacements.

Methods

Patients in the NICU with T-CVCs placed between 11/2008 and 8/2015 (n = 134) or PICCs placed between 7/2013 and 10/2015 (n = 467) were included. Demographics and outcomes were compared.

Results

The most common indications for line placement were parenteral nutrition for PICCs (74%) and lack of access for T-CVCs (53%). T-CVCs had a greater proportion of idle days (T-CVC- 25.2% vs PICC- 5.1%, p < 0.001) and removal within 24 h of discharge (T-CVC-53% vs PICC-5.8%, p < 0.001). Conversely, 81% of PICCs were removed within 24 h of nonuse. Line replacement after removal for nonuse was required in 6% of PICCs and zero T-CVCs. In both groups, the central line-associated bloodstream infection (CLABSI) rate was lower in idle lines compared to ones in use.

Conclusion

Patients treated with PICCs and T-CVCs are different populations and should have different guidelines for removal. In neonates with difficult access, the low risk of CLABSIs in idle surgically placed catheters may justify maintaining access until discharge.

Type of study

Treatment study.

Level of evidence

III.  相似文献   

19.

Background

Teratomas originating from the stomach are extremely rare and account for less than 1% of all cases of teratomas. This site of occurrence has unique diagnostic and management issues.

Methods

A single centre case-record review of gastric teratomas presenting between January 2000 and April 2017 was performed.

Results

Thirteen children were found to have gastric teratomas. Presenting features were abdominal distension in 12 (92%) and palpable abdominal mass in 9 (69%). At operation, 8 (61%) were exogastric tumors. The tumor was excised with partial gastrectomy (n = 7, 54%), total gastrectomy (n = 1, 8%), partial gastrectomy and limited transverse colectomy (n = 2, 15%), and excision of small part of serosa (mucosal sparing) (n = 3, 23%). Histopathologically, these were identified as mature gastric teratomas in 8 (61%). Three (23%) children died postoperatively.

Conclusion

Gastric teratomas are rare, with the majority described as exogastric. Partial gastrectomy is always needed, but occasionally complete gastrectomy is necessary. Overall survival is > 75% in our experience.

Level of evidence

IV  相似文献   

20.

Importance

Appendicitis is a common, potentially serious pediatric disease. An important factor in determining management strategy [whether/when to perform appendectomy, duration of antibiotic therapy/hospitalization, etc.] and predicting outcome is distinguishing whether perforation is present.

Objective

The objective was to determine efficacy of commonly assessed pre-operative variables in stratifying perforation risk in children with appendicitis.

Design

A retrospective analysis of consecutive cases was performed.

Setting

The setting was a large urban hospital pediatric emergency department.

Participants

Four hundred forty-eight consecutive cases of CT [computerized tomography]-confirmed pediatric appendicitis during a 6-year period in an urban pediatric ED [emergency department]: 162 with perforation and 286 non-perforated.

Main outcome(s) and measure(s)

To determine efficacy of clinical and laboratory variables with distinguishing perforation outcome in children with appendicitis.

Results

Regression analysis identified 3 independently significant variables associated with perforation outcome – and determined their ideal threshold values: duration of symptoms > 1 day; ED-measured fever [body temperature > 38.0 °C]; CBC WBC absolute neutrophil count > 13,000/mm3. The resulting multivariate ROC [receiver operating characteristic] curve after applying these threshold values gave an AUC [area under curve] of 89% for perforation outcome [p < 0.001]. Risk for perforation was additive with each additional predictive variable exceeding its threshold value, linearly increasing from 7% with no variable present to 85% when all 3 variables are present.

Conclusions

A pre-operative scoring system comprised of 3 commonly assessed clinical/laboratory variables is useful in stratifying perforation risk in children with appendicitis.Physicians can utilize these factors to gauge pre-operative risk for perforation in children with appendicitis, which can potentially aid in planning subsequent management strategy.

Level of evidence

III.  相似文献   

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